The NOD audit illustrates 30% reduction in PCR complications in cataract surgery since 2010. This equates to around 2,500 less complications annually.

In 2010, the overall unadjusted PCR rate was 2.0% (unchanged from pre-2006) and in the most recent year this has reduced to 1.4%.

Cataract surgery is the most frequently undertaken NHS surgical procedure with approximately 400,000 cataract operations undertaken in England and 20,000 in Wales in the 2016 - 2017 NHS year. This report is a snapshot of cataract surgery quality from 83 NHS funded centres in England and Wales.

Two primary indicators of surgical quality are audited.

1. The term **Posterior Capsular Rupture or Vitreous Loss or Both (PCR)** refers to a breach of the normal barrier between the front and back parts of the eye. PCR can arise as a complication of cataract surgery and may allow vitreous (a transparent substance with the consistency of egg-white which occupies the space inside the eye behind the lens) to move forward into the front part of the eye. When PCR occurs, it increases the risk of loss of vision after surgery.

2. **Visual Acuity (VA)** Loss (visual harm related to surgery): for cataract surgery, the most important outcome is vision; this is what matters most to patients. Vision which is worse after the operation than before is identified as an adverse outcome.

This is the second prospective national annual report and includes data on 183,812 eligible cataract operations for the period 01 September 2016 to 31 August 2017, from 148,785 patients. Key findings

- **First treated eye cataract surgery**

  - 183,812 eligible operations performed in 83 participating centres have been analysed
  - 110,228 (60%) operations performed for first eye cataract surgery
  - 76 years median age at the time of first eye cataract surgery (range: 18.1 – 107.7)
  - 27,610 (25%) patients were recorded as having diabetes mellitus at the time of their first cataract operation
  - 1,073 (1%) patients were recorded to be unable to lie flat
  - 1,335 (1.2%) patients were recorded to be unable to cooperate during the operation

- **Second treated eye cataract surgery**

  - 73,182 (40%) operations performed second eye cataract surgery
  - 77 years median age at the time of second eye cataract surgery (range: 18.4 – 104.9)
  - 19,718 (27%) patients were recorded as having diabetes mellitus at the time of their second treated eye surgery
  - 516 (0.7%) patients were recorded as being unable to lie flat
  - 651 (0.9%) patients were recorded as being unable to cooperate during the operation

- **Visual Acuity (VA) data returns are improving – 64% operations had both pre-operative and post-operative VA data recorded**

- **The operations were performed by 1,908 surgeons**

- **201 patients had simultaneous bilateral cataract surgery**

- **1.4% of operations overall were affected by Posterior Capsular Rupture (PCR). To more closely reflect the observed average for consultant surgeons the rate for adjustment revised to 1.1% (previously 2.0%)**

- **0.7% Visual Acuity (VA) loss rate, lower than last year’s overall observed rate of 0.81%**

  - To more closely reflect the average VA loss rate, the rate for adjustment revised to 0.9% (previously 1.5%)

1. Recommendations for Patients

1.1 Information has been made easily accessible to the general public

1.1.1 Patients, carers and those with an interest in cataract surgery are encouraged to access and view data regarding their local services. Information about the quality of cataract surgery can be viewed online on the National Ophthalmology Audit Database website and the HQIP website. In addition, data can be accessed on the NHS Choices website

1.1.2 Patients should ensure they discuss and understand the risks and outcomes of any eye surgery with their consultant

1.1.3 Information on cataract surgery is available from hospital trusts and Health Boards. Further information about cataracts can also be obtained from the charity organisations such as RNIB (Royal National Institute of Blind)

2. Recommendations for Providers of contract surgery

2.1 Publicly promote your commitment to fostering good professional practice by involvement in the audit

2.2 Support the improved use of electronic data collection and data completeness in your organisation, enable staff to implement change. Complete data helps ensure all relevant factors such as case complexity are submitted to the audit and can be included in the NOD analysis

2.3 Identify specific areas that need improvement by comparing your results against past performance

2.4 Promote use of the audit information in medical revalidation and appraisal

2.5 Encourage use of the EMR audit tools for continuous monitoring of results for early detection and correction of possible increases in adverse event rates

2.6 Care providers should review their patient pathways to maximise the recording of both preoperative and postoperative VA data for every operation

3. Recommendations for Surgeons

3.1 Use your audit outcomes report in appraisal discussions

3.2 Identify specific opportunities for improvement by comparing your results against peers and your own past performance

3.3 Use the EMR audit tools for continuous monitoring of your results for early detection and correction of possible increases in adverse event rates 4. Recommendations for Commissioners

4.1 An increase of around 50% in cataract operations is predicted over the next 20 years (25% increase over the next 10 years - RCOphth Way Forward), plan services appropriately using NOD and other data

4.2 Check the 2017 NICE guidelines on cataract surgery (recommendations for commissioners 1.9)

4.3 Include submission of data to the NOD as a lever of quality in supplier contracts

4.4 Establish quality focused contracts with providers which include requirements for reporting of National Audit based outcomes

4.5 Establish contracts with community services which require return of postoperative VA and refractive data back to the surgical provider through use of the audit tools

5. Recommendations for the Regulator

5.1 When inspecting NHS organisations, information regarding national audit commissioning, participation and performance should be routinely requested from commissioners and providers of cataract care

5.1.1 Regulators should expect participation in national audits with audit results made available to them when inspecting NHS organisations

5.1.2 All providers of care should be expected to be in a position to provide quality assurance regardless of whether they are traditional NHS centres or independent providers

Next Steps

- The audit will extend coverage to include more centres in the next audit period, 01 September 2017 - 31 August 2018. Currently 111 of 122 traditional NHS cataract providers and two independent sector providers have indicated that they wish to participate in the audit going forward

- The audit is piloting the feasibility of collection of PROM (patient reported outcome) data to improve understanding of the impact of cataract surgery on patients

The full annual report is available on the NOD audit website www.nodaudit.org.uk/resources/publications-annual-report